Five risks for training in Emergency Medicine. St.Emlyn’s

five-risks-when-training-in-em

DISCLAIMER: the below tips are based on my conversations with trainers and trainees. It’s unashamebly anecdotal but I make few apologies for that. I’ve supported emergency medicine trainees from all around the world and a few themes have come through. Despite the lack of ‘hard’ evidence, I very much hope you will enjoy the read, give some thoughts to the content and maybe even take something home from it. As with all St.Emlyn’s posts, I hope this informs the debate, please comment and get involved.

As an Emergency Medicine consultant working in a large Major Trauma Centre in the northwest of England, one of my roles is to supervise the career progression of junior trainees working in our delightfully cosmopolitan department. In the UK, this role includes not only shop floor work supervision but also an annual process called “appraisal” where we review the performance of our colleagues on distinct domains like communication, continuous professional development, complaints, probity issues etc. Trainees will be familiar with this as the ARCP process, we try and do something very similar for all our trainees.

Having trained and worked abroad before relocating to the UK, I am often allocated international medical graduates (IMGs) for supervision. This is a group with many of the same aspirations that our deanery based trainees have, but they face different challenges and have a slighty different career path (e.g. CESR rather than CCT). I’ve supported a myriad of colleagues come who have come to work and play with us here in Virchester. Some have stayed long term, some have gone after a period of training and we’re glad to see a few returning after training for a time elsewhere.

Even though we are a considered a major training centre, the majority of our junior doctors are not in official HEE training posts. Much work has focused on the retention of ‘official trainees’ but it’s important that we don’t forget that our workforce is much more complex and diverse than those on ‘official’ training programs. We also know that the retention of staff (both nursing and medical) is an issue on the British Isles and this is a complex, multi-factorial problem.

This blog attempts to have a look at some of the potential reasons behind this and I hope it will help future and present generations of EPs tackle this problem in our noble profession and maybe even beyond. It hopes to talk about some of the pitfalls that might push our friends and colleagues off the righteous path to Emergency Medicine nirvana (a job with me here in Virchester being the greatest EM post of them all 😉 ).

So what might push us off that path in EM and in medicine in general?

 

DON’T EXPECT FAST RESULTS

This is a common mistake mostly made by (but not exclusively!) juniors in training. Enthusiasm is a good drive but you have to combine it with some common sense, be realistic, and have sound time management skills. I often have trainees who during their annual appraisal lay down plans to attend half a dozen of courses, the same amount of conferences and complete a postgraduate exam within the following twelve months. Now, you have to pace yourself or combined with the fast-paced and stressful job we do daily, you will end up overworked and fatigued (I talk about fatigue in more detail a bit further down). Failures are likely to result in frustrations and you are likely to end up in an endless vicious circle of failure – low mood – low drive – repeated failure.

Try to be SMART when setting objectives with your supervisor. This is a concept by Peter Drucker and George T. Doran and is an acronym that stands for:

Specific – you need to specifically target a particular area for improvement you have identified and agreed upon with your supervisor (say you want to improve your competence/skills in central line insertion using ultrasound guidance)
Measurable – you should be able to quantify or at least suggest an indicator of progress (does your college curriculum specify how many of these you need to have completed to be deemed competent and be an independent practitioner?)
Assignable – specify who will do it (in this case it will obviously be YOU but can you share your workload with a colleague or involve others. Playing with someone else is always so much more fun than playing alone!)
Realistic – mark down what results can realistically be achieved, given the available resources (you are unlikely to achieve competency in central insertion nowadays in the UK if you have not completed your ultrasound competencies first)
Time-related – specify when the result(s) can be achieved (be realistic as if you are on short rotation you might not be able to achieve complex competences that require time and practice). Have you ever considered using a Gantt chart to help you with this? I always find this helpful as it helps to keep things in time perspective.

 

WHAT ABOUT THE FEAR OF FAILURE AFFECTING YOUR DESIRE FOR SUCCESS?

This links somewhat to the above point. Failure is part of life and I have noticed that some of our trainees lately are not very good at coping with setbacks/failures/delays in career progression. You however have to remember that there is no such thing as an always successful colleague (sorry if you thought you were all time awesome). We all have our weaknesses, down periods and it is important to accept our failures and make them part of our career progression. Do not get stuck in the past! A critical incident at your workplace should be used as a reflective tool and you have to absolutely make this a weapon (rather than a hindrance) in your progression. After all, there can be only three outcomes after a setback: you fly, you dive or you thrive. The outcome will be (mostly) determined by you!

Social media can be a bit of a curse in this regard. The image people project on their twitter accounts can sometimes appear that everyone else is having a wonderful time (or not). They are probably just like you, living with the ebb and flow of life. Don’t worry, we’re all the same.

 

WHAT ABOUT THE FEAR OF THE FUTURE?

I see this very rarely but more in senior trainees who are getting close or are just over their exit exams. In the UK, the end of emergency medicine training is marked by a fellowship exam (you can read more about the structure of the FRCEM – the fellowship of the Royal College of Emergency Medicine here). A minority of senior trainees, however, are somewhat reluctant to take up their first consultant post, or this stage of their career is accompanied by a certain level of anxiety. This is probably somewhat understandable as this is considered to be a big step, and let us face it, exams do not prepare us for everything to come.  At this stage, some will stop believing in themselves resulting in the above-mentioned anxiety. I am not sure I have the right advice for these folks apart from the fact that many have trodden the same path and have succeeded paternalistic. Trust me, you will be well prepared for what faces you in Emergency Medicine.  You will have accumulated a wealth of basic knowledge and clinical skills preparing for your exams: this is the best time to take on your first senior role. It’s also vital to remember that a consultant post these days in the UK means joining a team. You will have help and support from your consultant colleagues and they will really want to help you. There is still much to learn and it’s OK to ask. Don’t expect to be the finished article, you’re still on your learning journey. I am not sure taking out a year to travel the world is an option I would recommend (unless you do this in the context of working in somewhere different to your daily practice for further experience gain). I would also argue that taking a year out will only erode the precious wealth of knowledge and skills you have patiently accumulated.

There is a danger that clinical knowledge peaks around the time of qualification as a consultant. This would be a disaster as your consultant life is longer than your trainee one, and medicine constantly changes. However,  the work we do needs to be collaborative combining up-to -date knowledge (often the senior trainee) and gestalt (often the consultant): the trick is to find the right balance between these. One of the things you must learn as a consultant is how to learn new things and keep up to date so that you maintain the ability to train and the respect of your trainees (we all know the consultant who is so out of date that you can”t learn from them). We have covered in a previous blog post how to deal with the registrar who knows more than you here. A senior clinician consciously or subconsciously possesses some other skills which can be only acquired with years of experience and that is leadership skills, gestalt etc. that can only add on to a firm knowledge of basic science. Work and learn with them.

The skill is to find that right balance between competence and confidence within yourself and your team to beat that so often quoted Dunning-Kruger effect. Ignoring or subconsciously being unaware of this is described as “being on top of mount stupid” by my friend and colleague Sandra Viggers from Denmark (great quote Sandra!). If you have not heard about this effect yet, it can be defined as the metacognitive inability of the unskilled to recognise their own ineptitude and evaluate their own ability accurately. Food for thought…

 

HOW ABOUT OVERWORK AND FATIGUE?

The nature of our job implies that we have to work shift patterns including twilights, nights, bank holidays and weekends shifts. Any “mortal” out there would say that this is completely unsustainable and quite frankly…nuts! This work sequence will undoubtedly have a significant impact on our general mood, potentially on our physical and/or mental health. Add to this the usual stressors of life (relationships, mortgages, loans etc.) and it is not a real surprise to see that some of us choose not to continue on this emotionally and physically demanding career path. You have to work around this somehow as this career choice was ultimately yours (well, I very much hope so!) and you will be doing this job for quite some time. People always talk about finding that famous but elusive work-life balance. I, however, always suggest to my juniors to try to find a life-work balance. In other words, life (relationship, kids, fitness, friends etc.) should come before work. Simply put, how would you have a job if you have not got a life? The team from St.Emlyns have recently recently provided some top tips on sleep hygiene and how to look after yourself to become more resilient at your workplace.

 

AVOIDING BECOMING A VICTIM OF THE SYSTEM

We have to admit, we all have been through ups and downs in life. A relationship that ends, an exam that does not work out as planned, a loss in the family, a day at work involving end of life care etc. All of these will undoubtedly have an effect on our mood and morale. It is important to acknowledge that this is normal but be consciously aware of it to be able to deal with the effects. Like a period of mourning, this should however fade away either passively with time or actively helped by yourself. It does you no good dwelling on the past which cannot be changed. You can however change, shape your future but only if you deal with your past. In other words, do not let your past shape your future. This is easy to say but there are loads of support mechanisms out there available for all of us.

  • Talk to a friend or family member: sometimes even just talking about that bad day at work does help a lot. I call it the “hello darling, I am home” method.
  • Seek professional help: there is no shame in seeking the help/advice or support of a clinical psychologist. In the hospital where I work, this service is available for free and I can only recommend it to my colleagues having attended one session in the not so distant past.
  • You feel like your career path is leading nowhere despite multiple consultations with colleagues and your supervisor? Have you thought about seeking the input/help of a career coach? Just like professional footballers, I did this about a decade ago when despite all my efforts, I did not seem to be progressing in my profession. It was a worthwhile experience which indirectly landed me in my current job, which I often describe as the best job in the world!
  • Practising mindfulness, yoga, relaxation (and the list goes on!) are also options you can explore. In the era of the internet, there is really nothing you cannot at least enquire about and see if it fits your needs.

 

FINAL THOUGHTS

Our daily job takes place in a fast-paced, often stressful environment which will have some impact on our mood and influence our career choice/progression. There is no doubt we will have ups and downs during this career development where we have to overcome obstacles and most importantly ourselves. The only thing we have to remember is that we cannot look after our patients if we do not look after ourselves: so be kind to yourself too!

 

Janos

vb

@baombejp

 

PS: I would very much welcome your thoughts and experience in the form of comments at the bottom of this blog. We can only learn from each others.

 

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4 Comments

  1. Pingback: Five risks for training in Emergency Medicine. St.Emlyn’s – Global Intensive Care

  2. Raj

    Dear Dr Janos,
    I hope you’re doing good. I’m so glad that you wrote this blog and shared your thoughts and experiences. I am a 3rd year trainee in emergency medicine in Ireland . I am going through a tough time at the moment regarding my carrier in EM and your blog does mention quiet what a few things that I felt or expected. I feel that you would be able to provide play with some valuable suggestions/advice. If you could kindly provide me with your email address, so that I could share my thoughts with you. Thank you. Have a good day.

    Reply
    1. Janos Baombe (Post author)

      Hey Raj.
      I hope you are well.
      I have emailed you directly!

      Janos

      Reply
  3. Anu Mitra

    Great post Janos. I’m about to put the URL for this post into my FOAM of the week email! Perfect advice for higher trainees, thanks.

    Reply

Thanks so much for following. Viva la #FOAMed

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